DOT Physical Form | RiteCare Medical Office P.C

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Medical Examination Report Form

(for Commercial Driver Medical Certification)

PERSONAL INFORMATION

Last Name: First Name: Middle Initia: Date of Birth: Age: Street Address: City: State/Province: Zip Code: Driver’s License Numbe: Issuing State/Province: Phone: E-Mail (optional): CLP/CDL Applicant/Holder *: Yes No

Driver ID Verified By **:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Yes No Not Sure

DRIVER HEALTH HISTORY

Have you ever had surgery? If “yes,” please list and explain below Yes No Not Sure

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? Yes No Not Sure

If “yes,” please describe below.

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

Do you have or have you ever had:	Yes	No	Not Sure		Yes	No	Not Sure
1. Head/brain injuries or illnesses (e.g., concussion)				17. Unexplained weight loss
2. Seizures/epilepsy				18. Stroke, mini-stroke (TIA), paralysis, or weakness
3. Eye problems (except glasses or contacts)				19. Missing or limited use of arm, hand, finger, leg, foot, toe
4. Ear and/or hearing problems				20. Neck or back problems
5. Heart disease, heart attack, bypass, or other heart problems				21. Bone, muscle, joint, or nerve problems
6. Pacemaker, stents, implantable devices, or other heart procedures				22. Blood clots or bleeding problems
7. High blood pressure				23. Cancer
8. High cholesterol				24. Chronic (long-term) infection or other chronic diseases
9. Chronic (long-term) cough, shortness of breath, or other breathing problems				25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
10. Lung disease (e.g., asthma)				26. Have you ever had a sleep test (e.g., sleep apnea)?
11. Kidney problems, kidney stones, or pain/problems with urination				27. Have you ever spent a night in the hospital?
12. Stomach, liver, or digestive problems				28. Have you ever had a broken bone?
13. Diabetes or blood sugar problems Insulin used				29. Have you ever used or do you now use tobacco?
14. Diabetes or blood sugar problems Insulin used				30. Do you currently drink alcohol?
15. Fainting or passing out				31. Have you used an illegal substance within the past two years?
16. Anxiety, depression, nervousness, other mental health problems				32. Have you ever failed a drug test or been dependent on an illegal substance?

Medical Examination Report Form

(for Commercial Driver Medical Certification)

MEDICAL RECORD #